The CMS Blog

Encouraging Innovation to Fight Medicaid Fraud

By Julie Boughn 

The Centers for Medicare & Medicaid Services (CMS) is committed to fighting Medicaid fraud, which diverts funds from needed medical care for the most vulnerable Americans.  That’s why we’re announcing a challenge – the Provider Screening Innovator Challenge – to develop software tools that will help stop fraudsters from entering the Medicaid program under the pretense of serving patients.

The Provider Screening Innovator Challenge encourages private sector competition to develop new software that can screen potential Medicaid providers and keep bad actors from ever getting into the program.  Through a series of contests over the next 8 to 9 months, expert software developers will work to create software products, and the best ideas will be awarded prize money.   A total of $600,000 is available for prizes, funded by the Partnership Fund for Program Integrity Innovation, a program within the Office of Management and Budget.

The new software products will include enhanced screening data, such as the results of site visits, criminal background checks, and identity verification.  Fraudsters who try repeatedly to enter Medicaid by altering their applications with a slight change will also be blocked.  The software will also capture licensing information and financial data to spot and stop risky providers.

CMS is conducting this Challenge in partnership with the National Aeronautics and Space Administration, Harvard Business School, the State of Minnesota, and TopCoder (an online community of software engineers, computer scientists, and digital creators).

We eagerly await the ideas and products offered through the TopCoder community to help keep bad actors out of State Medicaid programs.  CMS will also be working with additional States to help us in finalizing software requirements as well as piloting the new software.

The first contest begins May 30^th at 6:00 p.m. Eastern Time. Registration information is available at the Center of Excellence for Collaborative Innovation Challenge portal: http://community.topcoder.com/coeci/.

Further information about the Provider Screening Innovator Challenge is available at www.medicaid.gov.

Ready for the 2012 SHIP Conference?

By Vicki Dufrene, Louisiana SHIP Director

Late spring means the annual SHIP conference is on its way—the 18th Annual SHIP Director’s Conference will be held June 4—7 in Atlanta.

It’s hard for me to believe that almost a year has passed since I found myself surrounded by dear friends and colleagues trying to absorb as much information as possible to help us better serve the aging network in our respective states.

This year’s theme is “Yesterday, Today and Tomorrow…Navigating Healthcare Changes Together.”  Health reform is on the horizon and this conference will give us insight and information to guide our staff, partners and volunteers through the maze of new challenges that will face us as we prepare for 2014.

It’s also a great opportunity to network, share best practices, talk about lessons learned, and learn about new Medicare programs and initiatives.

I’m looking forward to seeing my peers, friends and confidants, as they have proven to be a valuable asset—and even a source of comfort—over the past year.  At last year’s conference, I received a call from my office advising that two of my co-workers were killed in the line of duty.  As my staff and I gathered together to understand what was being told to us, the SHIP network extended their hearts, arms and prayers to comfort us when we needed it the most.  At this conference I hope to thank each one personally for their loving support and encouragement.

The need for a “Strong Start” in life

By Marilyn Tavenner, Acting Administrator for the Centers for Medicare & Medicaid Services

Like most of us, you probably know someone who had a baby born prematurely. These children are at greater risk for complications at birth as well as for developmental and health problems that can impact their quality of life as adults. Premature births are also an economic issue– preterm and premature births cost our country and hard-working families at least an estimated $26 billion each year.

Recently, a report from the World Health Organization, the March of Dimes, Save the Children, and the Partnership for Maternal, Newborn and Child Health found that more than half a million babies in the United States are born preterm each year. That’s more than 130 other countries– almost tying us with Somalia, Thailand, and Turkey. Moreover, early elective deliveries still account for 10-15% of all deliveries in the United States. While the United States excels at treating premature and preterm newborns, it would be better if more of our babies were born at full term.

To safely reduce preterm and premature births, the U.S. Department of Health and Human Services launched the Strong Start initiative earlier this year.  Strong Start builds on the work of American College of Obstetricians, the March of Dimes, and many others to reduce early elective deliveries.  Strong Start also involves change in prenatal care delivery to reduce premature and preterm births and improve outcomes for high-risk pregnant Medicaid beneficiaries and their newborns.

Decreasing early deliveries means:

• More mothers get safe, evidence-based care and infants improve their chances for good physical and developmental health.
• Public and private payers may see lower costs because providers are performing fewer caesarian sections for failed inductions, there are fewer neonatal intensive care unit admissions, and there are fewer associated complications for the newborns.

As a mother, I know there’s nothing more important for a child than getting off to a healthy start.  With the right resources and tools, we can make sure mothers and children around the country get the best care possible to give children a strong start in life.

Let’s get mothers and newborns off to a strong start.  Learn more about Strong Start and what you can do to reduce the rate of premature and preterm births.

Information on Implementation of the Physician Payments Sunshine Act

On December 19, 2011, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule implementing the Physician Payments Sunshine Act, which was included as section 6002 of the Affordable Care Act of 2010.  This provision will provide important transparency in requiring reporting of payments or gifts to physicians, and physician ownership and investment interests.  During the 60 day comment period, CMS received over 300 comments from a wide range of stakeholders.

CMS is committed to addressing the valuable input received during the comment period, and to ensuring the accuracy of the data collected.  In order to provide time for organizations to prepare for data submission and to sufficiently address the important input we received during the rulemaking process, CMS will not require data collection by applicable manufacturers and applicable group purchasing organizations before January 1, 2013.

CMS intends to release the final rule later this year.  This timing will provide CMS with additional time to address operational and implementation issues in a thoughtful manner, and the ability to ensure the accuracy of the data that is collected.

Closing racial and ethnic gaps in access to care

By Cara V. James, Director of the Office of Minority Health

Did you know that 31% of Hispanics are uninsured, compared to 12% of non-Hispanic whites?  Or that less than one-third of African American adults with diabetes receive the recommended services?  Or that fewer than 40% of American Indian and Alaska Native adults over 50 have gotten screened for colorectal cancer?

April is National Minority Health month. Although we continue to make strides in improving health outcomes, it’s clear that racial and ethnic minorities, low-income Americans, and other underserved populations still lag behind the general population.  Racial and ethnic minorities often have higher rates of serious diseases, are less likely to get preventive care, and have fewer treatment options and less access to quality health care. They’re also less likely to have health insurance than the general population.

The Affordable Care Act is improving access to care for minority populations and other underserved groups in a variety of ways. The Affordable Care Act fills in current gaps in coverage for the poorest Americans by creating a minimum Medicaid income eligibility level across the country.  Beginning in January 2014, individuals under 65 with incomes below 133 percent of the federal poverty level will be eligible for Medicaid, so for the first time, low-income adults without children will be guaranteed coverage through Medicaid in every state.  Medicaid and Children’s Health Insurance Program eligibility and enrollment will be much simpler and will be coordinated with the newly created Affordable Insurance Exchanges.

Starting in 2014, Affordable Insurance Exchanges will make buying health coverage easier and more affordable. These new Exchanges will offer one-stop shopping so individuals can compare prices, benefits and health plan performance on easy-to-use websites. Financial help will be provided to low-income populations, which will help ensure that all Americans have access to quality, affordable health coverage, even if they lose a job, switch a job, move, or become ill.

The Affordable Care Act is also improving access to preventive care services. Research shows that use of preventive services is traditionally lower for minority populations, but now all people with Medicare can get a range of recommended preventive serviceswithout paying part B coinsurance or meeting the deductible.  These include certain tests for breast, colorectal, and other cancers, diabetes, cardiovascular disease screening, and intensive behavioral therapy for obesity.  A new benefit, a yearly wellness visit with your qualified and participating doctor, has also been added, and is also available without part B cost sharing. These free preventive services can help reduce health disparities and give everyone the chance to enjoy better health and a better quality of life.

People with Medicare also get a 50 percent discount on covered brand-name drugs while in the prescription drug coverage gap (known as the “donut hole”), and by 2020, the donut hole will be closed. This change will help relieve the financial burden for millions of seniors and people with disabilities across the country.

The health of racial and ethnic minorities is one of the focus areas for the Office of Minority Health at CMS.  OMH works not only to serve as a resource and liaison within and outside of CMS, but to help improve CMS minority health data, report on CMS progress in reducing disparities, and represent minority health interests in all CMS activities.

The gaps in health outcomes won’t change overnight. But with free preventive services, yearly wellness visits, and more affordable prescription drugs, we’re helping to increase access to care, reduce health disparities, and strive for health equity.

7 Ways to Protect Yourself from Medical Identity Theft

Peter Budetti, MD, JD, Deputy Administrator for Program Integrity

Fraud affects everyone. We’ve said it before – but this time we’re not just talking about people with Medicare. As my colleague Dr. Shantanu Agrawal and I pointed out in a recent article in the Journal of the American Medical Association, physicians are also vulnerable to a type of fraud called “medical identity theft.”

Medical identity theft happens when a fraudster uses your unique medical identifiers to bill insurance for items or services that you never provided or prescribed. Examples of these medical identifiers could be your National Provider Identifier (NPI), Tax ID Number (TIN), and medical licensure information. You pay for this kind of fraud with increased financial liabilities – you may be expected to pay taxes on earnings you never received, or repay insurance companies for payments on items or services that you never provided. You may also become the physician of record for services you had nothing to do with.

How to Protect Yourself

1. Keep your medical information up-to-date. Report any changes to Medicare, Medicaid, and other insurance companies, such as opening and closing of offices and moving between group practices.
2. Review billing notices. Actively review your Medicare remittance notices to make sure there are no items or services listed that you didn’t provide, including payments to you for services you didn’t provide.
3. Protect your medical information. There are things you can do to better protect your information. For example, before giving out your medical identifiers to potential employers or other organizations, check them out to be sure they’re legitimate. Only give your information to trusted sources.
4. Train your staff. Make sure your employees know the proper way to use and distribute your medical information, such as on prescription pads, electronic health records, and on other important documentation.
5. Educate your patients. Patients are victims, too. Medical identity theft leads to higher insurance costs. Also, if patients are charged for items or services they never received, they may be denied in the future when they really need them. Tell patients to be on the lookout for fraudulent activity on their explanation of benefits statements, and how to report fraud when they see it.
6. Report any suspected medical identity theft. If you believe you may have been the victim of identity theft, call the CMS program integrity investigative contractor in your region,which you can find at this location: http://www.cms.gov/MedicareProviderSupEnroll/downloads/ProviderVictimPOCs.pdf You may also report any suspected cases of medical identity theft to the Office of the Inspector General.
7. Protect your prescription pads. Keep your prescription pads in a safe and secure environment, so they can’t be used by fraudsters to obtain prescriptions you never prescribed.

Medicare fraud and identity theft affects everyone. That’s why it’s very important for all of us to work together to stop it.

2012: the Year of Meaningful Use

Marilyn Tavenner and Farzad Mostashari

Health IT plays a central role in building a 21^st century health care system—where care is safer, better coordinated and patient-centered, where we pay for the right care, not just more care. Increasing the adoption and use of Health IT is crucial, so we’ve set an ambitious goal for 2012: get 100,000 health care providers paid under the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs by year’s end. For us to succeed, we need you—the states and our many other health IT partners—to join us in this effort.

The EHR incentive programs, which began in 2011, give payments to eligible professionals, eligible hospitals, and critical access hospitals as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology. “Meaningful use” means providers need to show they’re using certified EHR technology in ways that improve care.

Health IT systems, including EHRs, help providers communicate better with each other about patient care, which reduces medical errors, helps cut down on paperwork, and cuts out needless duplicate screenings and tests. These all lead to better coordinated patient care and lower health care costs.

Thanks to the invaluable work of Health IT coordinators, Medicaid programs, Health IT regional extension centers (RECs), leading hospitals, public health departments, and other stakeholders, CMS and ONC made significant progress in getting providers to adopt and use EHRs during 2011:

• Over $2 billion in Medicare EHR Incentive Program payments were made between May 2011 and the end of February 2012.
• More than $1.8 billion in Medicaid EHR Incentive Program payments were made between January 2011 (when the first set of states launched their programs) and the end of February 2012.
• More than 59,000 eligible professionals and over 2,000 eligible hospitals have been paid by the Medicare and Medicaid EHR Incentive Programs.
• More than 120,000 providers, representing approximately 40 percent of primary care providers nationwide, enrolled with the RECs to get program information and help in adopting EHRs.

There’s every reason to expect that together we can increase these numbers greatly this year to reach our target of 100,000 providers. Working together with state Medicaid programs and CMS Regional Offices, many states are partnering with local stakeholder organizations to make sure providers get the help and encouragement to achieve “meaningful use,” and assistance with overcoming any barriers that are blocking their progress. Several states have already set ambitious targets:

•  Ohio has set a goal of having 10,000 providers receive EHR incentive payments in 2012, representing nearly 40 percent of all eligible professional and eligible hospitals in the state.
•  Washington State aims to have more than 7,000 providers receive EHR Incentive payments this year representing about 40 percent of the state’s eligible professionals and eligible hospitals.
•  California has set goals of 10,000 eligible providers receiving Medicaid payments and $500 million in incentive payments coming to the state by June.
•  New York State has set an initial target of over 6,000 eligible providers receiving incentive payments in calendar year 2012.

Many of our provider partners have stepped up to the challenge as well.  The National Association of Community Health Centers, the American Academy of Pediatrics, and the American Association of Family Physicians have engaged their memberships in achieving meaningful use in 2012.  The American College of Cardiology has set its own goal of 8,000 cardiologists by 2012 – one third of its membership!

By working together, the health IT community can make 2012 the Year of Meaningful Use.

Stage 2 Meaningful Use NPRM Moves Toward Patient-Centered Care Through Wider Use of EHRs

Farzad Mostashari, MD, ScM, National Coordinator for Health Information Technology

Marilyn Tavenner, Acting Administrator for the Centers for Medicaid and Medicare Services

Substantial evidence shows that higher adoption of Electronic Health Records (EHR) can save our health care system money, save time for doctors and hospitals, and save lives.  Thanks to the Recovery Act and the Medicare and Medicaid EHR Incentive Program, we have seen great success and momentum as we’ve taken the first steps toward adoption of this critical technology: to date, over 43,000 providers have received $3.1 billion to help make the transition to electronic health records; the number of hospitals using EHRs has more than doubled in the last two years from 16 to 35 percent between 2009 and 2011; and 85 percent of hospitals now report that by 2015 they intend to take advantage of the incentive payments.

We have just announced the second stage of the three stage process.  This reflects our desire to create ambitious, but achievable, goals that enable eligible professionals and hospitals to make incremental progress in adopting and implementing electronic health records (EHRs).  The three stages are:

• Stage 1 (which began in 2011 and remains the starting point for all providers): “meaningful use” consists of transferring data to EHRs and being able to share information, including electronic copies and visit summaries for patients.
• Stage 2 (to be implemented in 2014 under the proposed rule): “meaningful use” includes standards such as online access for patients to their health information and electronic health information exchange between providers.
• Stage 3 (expected to be implemented in 2016): “meaningful use” includes demonstrating that the quality of health care has been improved.

Today’s proposed rules focus on using EHRs to improve health and health care while reducing the burden on physicians and hospitals where possible. 

CMS’ proposed rule would specify the Stage 2 criteria that eligible providers must meet in order to qualify for Medicare and/or Medicaid EHR incentive payments.  It also would specify Medicare payment adjustments that, beginning in 2015, providers will face if they fail to demonstrate meaningful use of certified EHR technology and to meet other program participation requirements.  In addition, as we announced in a November 2011 “We Can’t Wait” announcement, Stage 1 has been extended an additional year for providers who attested in 2011 – meaning that these providers will have to attest to Stage 2 in 2014, instead of in 2013. 

The proposed rule announced by ONC identifies standards and criteria for the certification of EHR technology, so eligible professionals and hospitals can be sure that the systems they adopt are capable of performing the required functions to demonstrate either stage of meaningful use that would be in effect starting in 2014.

Together, these rules will encourage even more providers to participate and support more coordinated, patient-centered care. 

For details on today’s announcement, please visit

http://www.cms.gov/apps/media/press_releases.asp;

http://www.cms.gov/apps/media/fact_sheets.asp; and

www.healthit.gov/policy-research.

Fighting Improper Payments And Fraud – Protecting Taxpayer Dollars

By Marilyn Tavenner, Acting Administrator of the Centers for Medicare & Medicaid Services (CMS)

Fighting fraud and waste in the health care system is a top priority for the Obama Administration.  We are committed to using all resources at our disposal in these efforts – and they are paying off.

Just last week, the Departments of Justice and Health and Human Services (HHS) released an updated annual report showing that in FY 2011 anti-fraud efforts have recovered more than $4.1 billion in fraudulent Medicare payments – the second year in a row recovery efforts reached this unprecedented level.  Compare this to just $2.14 billion recovered in FY 2008.  Prosecutions are way up too:  the number of individuals charged with fraud increased from 821 in fiscal year 2008 to 1,430 in fiscal year 2011 – nearly a 75 percent increase.

But we know we need keep doing more to end the “pay and chase” model of fighting fraud.  We need to stop fraud and waste from happening in the first place.  Today we’re taking an important step to protect taxpayer dollars by reducing improper payments to Medicare Advantage plans, an action that is estimated to save $370 million in the first audit year alone.  By improving the way we audit Medicare Advantage contracts, we will reduce the payment error rate for the Medicare Advantage program  and that saves money for Medicare.

We are also using new, advanced techniques to fight fraud.  Starting last year, we have been using “predictive modeling” technology – similar to technology used by credit card companies to identify and fight fraud nationwide.  This effort is just getting started but it’s already making a difference. Since the predictive modeling system was activated, CMS has stopped, prevented or identified $20 million in payments through November 2011 that should not have been made.

In addition, predictive modeling has identified 2,500 leads for further investigation, 600 preliminary law enforcement cases under review and resulted in 400 direct interviews with providers who would not have otherwise been contacted.

Predictive modeling won’t reach its full potential in overnight, but it’s already making an incredible difference and will do even more in the weeks, months and years ahead.